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Thursday, February 3, 2011

When a patient is not a board question

I am really enjoying my Geriatrics rotation. Although my attending preceptor is primarily a geriatrician, he also sees some patients who are younger. I took a history on a patient who was younger than me today, in her early thirties.

She started off complaining about insomnia and headaches, and then said she had some sort of an "attack" earlier this week. She quickly added that her husband died suddenly three weeks ago, and her therapist recommended that she come to see her doctor. I immediately offered her my condolences.

My mind quickly flipped to a frequent practice board question as I gently asked her about other symptoms. A 40 year old man presents to an outpatient clinic complaining of insomnia, poor appetite, and feeling helpless and lonely. He frequently thinks of dying to join his wife. He lost his wife of 18 years five weeks before. Was she suffering from loss of appetite? Was she able to return to work? Had she thought about hurting herself? What did she mean by an "attack"?

Telling the difference between Bereavement-Related Depression (BRD) and Major Depressive Disorder (MDD) is a frequent sample board question that I have come across in various forms as I have been doing patchwork board review. Bereavement is an exemption from a MDD diagnosis for two months after the death of a loved one, while the duration of depressive symptoms only needs to be for two weeks otherwise. Board review questions often dance around this time period. This BRD exemption (and the duration of symptoms for MDD diagnosis in general) is also the subject of some controversy as experts are constructing the new Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-V), which is the guide to diagnosing mental illness.

I snapped out of my board review musings and continued to question and console the new widow. When I got up to leave the room, I strongly considered asking the patient if I could hug her. Since it was only my third day on the rotation and I was in the room with the physician's assistant, I decided against it. I think if this would be my own patient in my own practice in the future, I would not hesitate to ask. When I left the room and told the other student about it, I teared up.

She is seeing a therapist, and the doctor saw her and did what he thought was right, treatment wise. The doctor is very empathetic and kind, in my opinion, so I am sure he consoled her, too. I was not in the room when he saw her. Maybe he even hugged her.

For what it is worth, the day my mother died I had to take my 22 month old child to the pediatrician because she had been coughing and I wanted to be sure she could fly. It meant so much to me that our doctor hugged me. It will be nine years ago this July and I remember it clearly.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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